CHAPTER ONE
Who Drops Out of Premed, and Why?
In the introduction I described my experiences advising undergraduate students in the Human Biology program of Stanford University. For many of these students, something happens early in their undergraduate experience that causes them to turn away from medicine as a career. From repeated anecdotes, I have learned that a student’s early experience in chemistry courses is often a factor in that decision. However, these are simply anecdotes. Do they accurately reflect a larger pattern? Is it true that the premedical sciences, in particular chemistry, have the effect of “weeding out” many women and students from underrepresented minority (URM) groups who otherwise possess academic strengths and personal characteristics that seem well suited to a career as a physician? Before I could think about what approach to take in addressing this issue, I needed to know if these anecdotal impressions were accurate and could be supported by data. I needed to undertake a carefully thought out program of research addressing the question of who loses interest in premedical studies and why. If I were able to confirm that this “weeding out” process affects URM students disproportionately, these results would have potential significance for the ongoing policy debate about how best to increase the racial and ethnic diversity of the medical profession both in California and in the United States more generally.
The Need to Increase the Diversity of the Medical Profession
Increasing the racial and ethnic diversity of the medical profession in the United States has become a pressing national policy priority. In 1996 Jordan Cohen, then president of the Association of American Medical Colleges, called on the AAMC and on the leaders of U.S. medical schools “to bridge the appalling diversity gap that still separates medicine from the society it professes to serve.”1 Nearly a decade later, the AAMC issued a follow-up report that re-emphasized, both to the admissions committees of medical schools and to the country as a whole, the continuing imperative of expanding the racial and ethnic diversity of the medical profession: “As our nation becomes increasingly diverse, the need for and potential impact of a diverse physician workforce will become more pronounced.... [A]nticipating the change in the nation’s demographics represents an additional imperative for medical education to educate more minority physicians and physicians that are culturally sensitive and focused on patient care.”2
Material in this chapter was previously published as D. A. Barr, M. Gonzalez, and S. F. Wanat, “The Leaky Pipeline: Factors Associated with Early Decline in Interest in Pre-medical Studies among Under-Represented Minority Undergraduate Students,” in Academic Medicine 83 (2008): 503–11, and reproduced with permission of the publisher; and D. A. Barr, J. Matsui, M. Gonzalez, and S. F. Wanat, “Chemistry Courses as the Turning Point for Premedical Students,” in Advances in Health Sciences Education, published electronically in advance of print and reproduced here with permission of the publisher.
Twice in recent years the Institute of Medicine of the National Academy of Sciences has issued scientific reports stressing the importance of this issue. The editors of a 2001 study stated, “Many minority groups, including African Americans, Hispanics, and Native Americans, are poorly represented in the health professions relative to their proportions in the overall U.S. population.... Increasing the diversity of health professionals has been an explicit strategy of the federal government and many private groups.”3 A 2004 report titled In the Nation’s Compelling Interest concluded that “a preponderance of scientific evidence supports the importance of increasing racial and ethnic diversity among health professionals.”4
Despite this need for increased racial/ethnic diversity, the number of physicians from URM groups graduating from U.S. medical schools, including African American, Latino, and Native American graduates, has shown a steady decline from the peak rates seen in the mid-1990s. Paralleling the decline in the number of URM graduates from medical school has been a decline in the number of URM applicants to medical school.5
The decline in applicants and graduates has been even more acute in California. With a population that is both growing and aging, and with an increasing prevalence of chronic diseases, the State of California is expected to have a shortage of up to 17,000 physicians by the year 2015.6 Compounding this problem is the concurrent need to increase the racial and ethnic diversity of the medical profession in California. Of the projected increase of 12 million people in the state’s population in the next 25 years, 75 percent is expected to be among Latinos.7 Grumbach and colleagues, in analyzing the results of a survey of more than 60,000 California physicians, concluded that “the underrepresentation of Latinos and African Americans among California physicians remains dire.”8 Among Grumbach’s recommendations to address these issues is “invest[ing] in the educational pipeline preparing minority and disadvantaged students for careers in medicine and other health professions.”9 However, my experience at Stanford suggested that the “pipeline” of minority and disadvantaged students in California who are heading toward a career in medicine had sprung a leak. From anecdotal evidence conveyed to me by colleagues at the University of California (UC), I had every reason to believe that UC’s “pipeline” had also sprung a leak, with a profound impact on the ability of UC medical schools to train a diverse physician workforce.
In the early 1990s, UC’s five medical schools were enjoying substantial success in enrolling qualified medical students from URM groups, with 117 URM first-year students enrolling at a UC school. However, in the wake of new policies adopted by the UC regents and of Proposition 209 approved by California voters, the number of first-year URM students enrolling in UC medical schools fell to 63 in 2000.10 While that number has increased somewhat to an average of about 100 students per year for the past several years, this level remains well below the levels realized before Proposition 209. This drop in URM enrollment at UC medical schools was accompanied by a parallel drop in URM students from California who applied to medical school. In 1994, 711 URM students from California applied to medical school somewhere in the country; in 1999, this number had fallen to 476, a decrease of 33 percent. URM premedical students at Stanford appeared to be losing interest in a medical career early in their undergraduate experience. Was the same thing happening to students at UC Berkeley, the flagship campus of the UC system?
Understanding Why Students Leave Premedical Studies
Every year, Stanford University administers a survey to all incoming freshmen that addresses students’ academic and professional aspirations, asking: “At this point in your life, if you are thinking of pursuing a graduate degree, in which area(s) would you do so?” In 2001, 313 incoming freshmen indicated an interest in attending medical school after Stanford. Of these, 93, or 30 percent, were URM students (i.e., those who self-identify as African American, Latino, or Native American). That same year, 280 students who had done their undergraduate education at Stanford applied to medical school through the AAMC’s American Medical College Admissions Service. Of these 280 applicants, 38 were URM students, comprising slightly less than 14 percent of applicants.11 Notably, while there were 220 incoming premedical students who were not in a URM group, there were 242 applicants who were not in a URM group. In other words, in 2001 the decrement in students applying to medical school from students entering as premedical students was fully accounted for by the loss of URM students from the premedical pipeline that runs through the four years of the Stanford undergraduate experience.
TABLE 1.1.
Comparing the racial/ethnic and gender composition of entering premedical students at Stanford University (2001–2005) with that of medical school applicants from Stanford University (2001–2008)
Of course, it is difficult to generalize from a comparison of a single cohort of incoming freshmen premedical students with a single cohort of exiting medical school applicants. However, the discrepancy at that time was enough for me to begin to seek an explanation. Before I could fully document that URM students who enter Stanford are more prone to losing interest in a medical career than non-URM students, I would need to follow additional cohorts of incoming and exiting students. Accordingly, I gathered data from the fall of 2001 through the fall of 2005 on all students entering Stanford as freshmen and indicating an interest in a medical career, broken down by racial and ethnic group. In addition, I obtained data from the AAMC on all students from Stanford who applied to a U.S. medical school from the 2001 application cycle through the 2008 application cycle. I calculated the average number of incoming premedical students over this five-year period and compared it with the average number of medical school applicants over this eight-year period. The results are shown in table 1.1.
It can be seen that the results from 2001 were not anomalous. Between 2001 and 2005, an average of 108 URM students entered Stanford each year hoping to become physicians. Between 2001 and 2008, an average of 50 URM students from Stanford applied to medical school—58 fewer than entered Stanford with premedical aspirations, representing a decrease of 54 percent. URM students, on average, make up 29.8 percent of the entering cohort of premedical students and 17.0 percent of the cohort of applicants. This decrease in the number of URM students applying to medical school is seen disproportionately among URM women. By comparison, every year about 11 fewer non-URM students apply to medical school than enter as premeds—a decrease of about 4 percent. As with URM students, this decline is seen principally among women.
On the assumption that, in choosing among some of most talented high school students in the country, the Stanford Undergraduate Admissions Office rarely misjudges a student’s academic ability and potential, it appears that Stanford loses 58 otherwise qualified URM students from the premedical pipeline every year. While a substantial majority of these students stay at Stanford and graduate successfully, they appear to have given up their aspirations for a career as a physician.
Why does this happen? What makes these students change their minds? Do they find something more attractive that pulls them out of premed, or does something happen that pushes them out? Does anything like this also happen at UC Berkeley? These were the questions I felt compelled to answer.
Research Methodology Used to Study Premedical Students at Stanford
As noted above, Stanford University administers a survey to all incoming freshmen that records students’ academic and professional aspirations. For this phase of the research, the university’s Office of Institutional Research provided us with identifying information on all incoming students in the fall of 2002, 2003, and 2004 who responded to the question about career plans by indicating medicine as a probable area of study. This group of 1,101 students forms the initial study population. The Stanford Office of Human Subjects Research reviewed and approved our research protocol.
We developed a survey instrument that we administered to these students electronically. Approximately one week after freshman orientation, we sent an e-mail to each incoming student in the study population, asking him or her to participate in our study. Those who agreed to participate clicked on a Web link that took them to the consent page of our survey. We sent out two additional waves of e-mails to those students not responding to our initial request for participation.
After linking to the Web page with our survey and after giving consent for participation, students were asked to do the following: “Please choose a whole number between 1 and 10 from the Interest Scale which best describes your current interest in being premed.” The students were then shown a 10-point scale, with the following prompts located at the numbers indicated:
10 So committed to premed that nothing can stop me
9
8
7 Probably will be premed
6
5
4 Probably will not be premed
3
2
1 Absolutely no interest whatsoever in premed
Students could indicate only a single whole number in response. In earlier piloting of our survey instrument, students consistently recognized that “being premed” meant to undertake a course of premedical studies in preparation for applying to medical school. The survey also asked students to indicate which, if any, immediate family members are doctors.
We maintained a list of those students who responded to our initial survey request. We sent each of these students an e-mail between two and four weeks from the end of the freshman year, asking them to link to our survey and to respond again to the question about their current level of interest in premedical studies, using the same 10-point visual scale. We sent two additional rounds of e-mails to those students who had responded to our initial survey at the beginning of the year but had not yet responded to our end-of-year survey. Finally, we repeated the survey at the end of the sophomore year, again sending out two additional rounds of e-mails to those subjects not responding. We report data on the 362 students who responded to all three surveys (overall response rate 34.3%).
We used a test-retest methodology to assess the reliability of our 10–point interest scale, requesting approximately 15 percent of the respondents in one admission cohort, identified randomly, to complete a duplicate survey three months after having completed the initial survey. Twenty-four of the thirty-eight repeat subjects completed the retest survey. The Pearson correlation coefficient between students’ responses at these two times was 0.69 (p < .001).
In an initial pilot study of our survey instrument, we tested for possible response bias by telephoning 61 students who had not responded to the repeat survey administered at the end of freshman year. On the phone we asked them to rate the strength of their interest in premedical studies; we then compared their responses to 143 students who had responded and participated in the survey at the end of their freshman year. The mean interest level of the initial responders was 6.73 (95% CI: 6.36–7.11), while that of the nonresponders was 6.44 (95% CI: 5.77–7.12), suggesting that nonresponders to the follow-up surveys were less interested in continuing as premed than were those who did respond.
In addition to the data obtained from the student survey, the Office of Institutional Research provided us with the following data on each student: gender, principal racial or ethnic group (as identified by the student), zip code of family residence, SAT verbal score, and SAT math score. We categorized students into five principal racial/ethnic groups: white (not Hispanic), African American, Latino (Hispanic), Asian, Native American. We used the median household income for the zip code of the student’s family residence to estimate the household income of the student’s family. This estimation method has been shown to provide an appropriate estimate of family income when actual family-level data are not available.12 We excluded students whose family lived outside the United States and students who indicated “other” for race/ethnicity, giving a final study population of 1,056 students.
We compared the mean interest level for each of the five racial/ethnic groups and for each of the three time periods studied. We refer to the interest level at the beginning of freshman year as Time 1 (T1), at the end of freshman year as Time 2 (T2), and at the end of sophomore year as Time 3 (T3). We calculated a measure of change in individual student interest by subtracting the response at T1 from the response at T3. A positive value indicated an increase in interest, while a negative value indicated a decline in interest.
Research Methodology Used to Study Premedical Students at Berkeley
In order to address the question of whether underrepresented minority students who enter UC Berkeley with an interest in pursuing premedical studies also experience a change in career interest, we approached colleagues at UC Berkeley and asked their help to gather comparable data on incoming Berkeley freshmen. If URM students at UC Berkeley were to experience the same leakage from the premedical “pipeline” as we found among those students at Stanford, the ability of the UC system to meet its goal of increasing the diversity of the California medical profession would be substantially impaired.
While we were able to conduct our research at Berkeley in a way that paralleled that at Stanford, we encountered some important methodological differences at Berkeley. While Stanford gathers information on future career plans from all incoming freshmen, UC Berkeley at that time did not. Accordingly, we were required to send an initial e-mail to every incoming Berkeley freshman, asking whether s/he was considering a career in medicine following graduation. Those students who were considering medicine were then asked to link to a Web site at which our survey was explained and at which approved informed consent for participation was obtained.
At Stanford, when a student responded to any of the surveys, the computer server housing the survey was able to record that student’s unique identifier used for computer access. In this way we were able to link responses at the two time periods for individual students and compare changes over time at the level of the individual student. For Berkeley students, the computer server was not able to obtain a unique identifier for each survey respondent that would permit us reliably to link responses at the two times for individual students. Accordingly, in reporting our Berkeley data, we report mean responses of a specific racial or ethnic cohort and are able only to compare changes over time in cohort mean responses rather than individual student responses. We report data on students who entered Berkeley as freshmen in the fall of 2003, 2004, and 2005. Of these three cohorts, we were able to obtain data about the level of interest at the end of sophomore year in the first two cohorts.
Survey Results
Table 1.2 shows the average response to our survey for students at the beginning of the freshman year and the end of the sophomore year, sorted by racial/ethnic group and by school. A total of 1,036 Berkeley students responded to our survey at the beginning of their freshman year. Of these initial respondents, 589 also responded at the end of their sophomore year. We compare the interest level of these Berkeley students with that of the 362 Stanford students (out of an original sample of 1,056, overall response rate 34.3%) who responded to our survey at both times.
For African American, Latino, and Asian student groups, the initial level of interest is similar at the two universities. Native American respondents at Berkeley reported a lower initial level of interest than those at Stanford, while the white respondents at Berkeley reported a somewhat higher initial level of interest than those at Stanford.
Several interesting patterns can be seen in comparing the responses of Berkeley students and Stanford students. While Berkeley students and Stanford students generally start their freshman year with about the same level of interest, the decline in that level of interest is quite a bit steeper at Berkeley. White (loss of 2.98 points), Asian (loss of 2.27 points), and Latino (loss of 2.31 points) students at Berkeley lose more interest than white (loss of 1.05 points), Asian (loss of 0.37 points), and Latino (loss of 1.32 points) students at Stanford.
TABLE 1.2.
Racial/ethnic differences in the level of interest in pursuing premedical studies for students
at the University of California, Berkeley, and Stanford University
By comparison, African American students at Berkeley (loss of 1.36 points) and at Stanford (loss of 1.44 points) have a similar level of decline. However, while African American students at Stanford have the second-largest decline among all racial/ethnic groups, at Berkeley they have the smallest decline and end their sophomore year with the greatest interest in continuing premedical studies of all the racial/ethnic groups.
Native American students at both Berkeley (loss of 3.09 points) and Stanford (loss of 1.64 points) report the largest decline of all the groups. Compared to the other racial/ethnic groups at Berkeley, Native American students start out with the lowest level of interest and remain in that position at the end of sophomore year. At Stanford, Native American students start out with the highest level of interest and end with the second-highest level.
Analysis of Factors Associated with a Decline in Interest
Because we were able at Stanford to track responses over time for individual students and thus were able to link changes in interest level over time for each of these students, it was possible to test for those factors associated with the change over time in an individual student’s level of interest. Accordingly, we first calculated the change in interest for each student between the beginning of the freshman year (T1) and the end of the sophomore year (T3) by subtracting the value at T1 from that at T3. A positive value for this variable indicates an increase in interest, and a negative value indicates a corresponding decrease. We found that the distribution of this variable approximated a normal distribution. We used ordinary least squares regression to evaluate the associations between the demographic variables we had for the students and the value of (T3–T1). The results of these analyses are shown in table 1.3.
In the first step of the analysis (model 1) we entered only a variable indicating underrepresented minority status, confirming that URM students at Stanford have a larger drop in interest between T1 and T3 than non-URM students. In model 2 we add a variable for female gender. In this analysis, both URM status and female gender are independently associated with a larger decline in interest. In a separate analysis, we tested for an interaction effect between URM status and female gender. We found no interaction; entering the interaction term weakened the fit of the model (data not shown).
In the third step (model 3) we entered median household income by zip code as a marker of family socioeconomic status (SES). While the coefficient for income was not significant, its inclusion resulted in the URM variable no longer having a significant association, suggesting an association between URM status and median household income. We tested for such an association and found that mean household income in zip codes of URM families was $62,439 (95% CI: $57,311–$67,577) while that of non-URM families was $83,332 (95% CI: $79,490–$87,175).
In model 4 we added the variables for SAT scores and ratio, and the variable for the number of family members who are doctors. In this model the only variable with a significant association is family members who are doctors. Female gender no longer has a significant association with the change in level of interest. URM status continues without a significant association. We find no significant association for either individual SAT scores or the ratio of SAT scores. While the explained variance (as measured by the value of R-squared) has gone up in model 4 as compared to model 3, the overall fit of the model (as measured by the F value) has gone down. In a separate analysis, we used cross tabulation analysis to determine if (a) URM students and (b) women students tend to report fewer family members as doctors. We found both associations to be significant (data not shown).
TABLE 1.3.
Results of least-squares regressions evaluating factors associated with a change
in the level of interest in premedical studies (T3–T1)
The results of our analyses of changes in Stanford students’ level of interest suggest three principal findings:
1. Between the beginning of their freshman year and the end of their sophomore year, the premed interest level of URM students declines more than the interest level of non-URM students; this decline is independent of gender.
2. In the same time period, the premed interest level of female students declines more than the interest level of male students; this decline is independent of URM status.
3. Both the number of family members who are doctors (a significant association) and family income (a weak but nonsignificant association) act as intervening variables that replace either URM status or gender as significant predictors of change in level of interest in the models we tested.
Why Do Students Lose Interest?
We learned that, on average, students at both Stanford and UC Berkeley lose interest in continuing premedical studies between the beginning of their freshman year and the end of their sophomore year. The magnitude of the decline is greater at Berkeley than at Stanford. At Stanford we were able to document that the decline in interest disproportionately affects women and URM students. The next question for us was why, in the students’ minds, these changes occur. To answer this question, we conducted a series of follow-up interviews at both campuses.
At Stanford we conducted follow-up interviews with 68 of the 362 responding students, administered between the end of the subject’s sophomore and senior years. In selecting students for interviews, we attempted to balance students who had reported a decrease in their level of interest in premed with those who had reported an increase in their level of interest. We further divided these two groups into URM and non-URM, then randomly selected students from each group for interview. In doing so, we oversampled URM students.
At Berkeley we conducted one-on-one interviews with 63 of the responding students, also administered between the end of the subject’s sophomore and senior years. We divided respondents into two groups, URM and non-URM, and randomly selected students from each group for interview. In doing so, we over-sampled URM students, getting a final interview sample of 29 URM students and 34 non-URM students.
Students had the choice of in-person or phone interviews. In either case, we provided students with the approved consent form (written for in-person, verbal for phone). Each interview was recorded and subsequently transcribed verbatim. A URM interviewer interviewed all URM subjects; a non-URM interviewer interviewed the non-URM subjects.
The interview contained two questions.
1. “What were the factors that led to the [increase] [decrease] in your level of interest in being premed?”
Before finalizing our interview scripts, we had conducted an initial pilot study consisting of informal interviews with several premedical students. In those pilot-study interviews, subjects often mentioned particular courses that they said discouraged their interest in medicine. Based on those preliminary findings, we included question 2 as a follow-up:
2. “Were there any specific courses at [Stanford] [Berkeley] that discouraged your interest in medicine?”
We analyzed data from each of the interview questions separately. For each question, two members of the research team took a sample of the transcripts and closely read the responses in those transcripts. The researchers then discussed these responses in depth. Based on their examination and discussion of this first sample of transcripts, the researchers identified an initial set of response categories. The two team members then took a second set of transcripts, closely read the response in each transcript, and identified response categories in this second sample. This was done to determine whether, and to what extent, the categories in the initial set of categories also represented the data in the second set of transcripts. After this initial coding process with two samples of transcripts, all transcripts (including those in the first two samples) were analyzed using the response categories derived from this process.
Results of Interviews with Stanford Students
As shown in table 1.4, the most frequent response category for the first question was “courses taken at Stanford,” mentioned by 36 of the 68 students (53%). (Recall that students were not asked specifically about the influence of courses they had taken until the next question was asked.) The second most frequently mentioned influence was contact with physicians, identified by 13 students (19%).
The way a student reacts to specific courses taken at Stanford as a freshman or sophomore appears to have an important influence on that student’s ongoing level of interest in continuing in premedical studies. An especially positive response to those courses will be associated with an increase in interest, while an especially negative response will be associated with a decrease in interest. This contrast is illustrated in the following responses to this question. The first two experienced an increase in interest in premed, and the second two a decrease in interest.
“Information—I took biology at Stanford—the bio core—so understanding the way they actually presented material in medical school curriculum, as well as the topics covered.” (URM male, interest level increased)
“The realization that I could handle the academic workload. You hear all those rumors about ‘weeder’ courses, but I saw that I could do it. I feel I have a decent grasp of what I expect and what is expected of me.” (non-URM male, interest level increased)
TABLE 1.4.
Comparing by underrepresented minority (URM) status and gender the factors contributing to a change in interest in being premed as reported during interviews by self-identified premed students entering Stanford University in 2002, 2003, or 2004
“Everyone says it’s [Stanford’s premed courses] more like a weeding-out process than anything [else] and I just ended up being one of those people.” (URM male, interest level decreased)
“I think I experienced the same distaste [as other premeds] for the large premed classes, like the Biology core. You think that no one wants to support you; they’re just out to get you.” (non-URM female, interest level decreased)
One-third of students whose interest had increased over the period of this study identified courses they took as contributing to that increase, while three-fourths of students whose interest had decreased over the period of this study identified courses they took as contributing to that decrease. The current courses offered to premeds at Stanford appear substantially more likely to discourage students’ interest in medicine as a career than to encourage that interest.
Having had contact with a physician during the first two years of college also appears to affect the level of students’ interest. In this case, that contact appears more likely to encourage students in maintaining their interest (23%) than to discourage that interest (15%). An exposure to research also seemed to play a role in increasing interest in premed for some students.
It should be noted that among students at Stanford who lost interest in premed, one in three (33%) reported that their interests had simply changed, without identifying a specific contributing factor. It is difficult to know if this change in interest is in reaction to or independent of the other negative experiences reported.
In comparing the responses of URM students with those of non-URM students, the pattern of responses is generally the same. Experience with courses was mentioned most frequently, with those losing interest substantially more likely to mention the effect of courses.
As shown in table 1.5, of the 35 students whose interest in premed increased, 26 (74%) identified at least one course they took during their first two years at Stanford that tended to discourage their interest in a career in medicine. Of the 33 students whose interest in premed decreased, 28 (85%) identified at least one course they took during their first two years at Stanford that tended to discourage their interest in a career in medicine. The responses of URM and non-URM groups were quite similar.
When we then looked to see what specific courses students mentioned as discouraging their interest in medicine, we saw a striking pattern: students identified chemistry courses between four and five times more often than the next category, biology. Other courses, such as physics and math, were mentioned only rarely. It is also instructive to note that, among students whose interest in premed had decreased, students often mentioned more than one chemistry course as having contributed to that decline.
TABLE 1.5.
Specific courses mentioned during interviews by students self-identified as premed entering
Stanford University in 2002, 2003, or 2004, in response to the question, “Were there any
specific courses at Stanford that discouraged your interest in medicine?”
For those students who mentioned at least one chemistry course as having discouraged their interest, we compared the frequency with which specific chemistry courses were mentioned. “Organic chemistry” was the course mentioned most frequently as tending to discourage students’ interest in medicine (19/54). “Chemistry” as a generic subject without mentioning a specific course (16/54), and inorganic chemistry (16/54) were each mentioned nearly as often as organic chemistry. Finally, “chemistry lab” was mentioned least often (3/54). These findings confirm those of Lovecchio and Dundes from an earlier study at a single institution.13 However, our findings suggest that the discouraging effects of studying chemistry as part of the early premedical curriculum are more extensive than organic chemistry alone. The following excerpts from the interview texts are typical of students’ responses:
“Chem 33 and Chem 36 [both organic chemistry] kinda discouraged me. It was difficult to get a helping hand.” (non-URM male whose interest level increased)
“Organic chemistry.” (URM male whose interest level increased)
“Chem 31 [inorganic chemistry] and Math—first quarter calculus—huge anonymous classes with bad TAs.” (non-URM female whose interest level decreased)
“The chem core, Chem 31/33. It’s tough and I think there’s a lot of students. There’s not a lot of professor-student contact. I felt the professor [was] somewhat abrasive at times.” (URM female whose interest level decreased)
Results of Interviews with Berkeley Students
As was the case at Stanford, when asked to identify factors that had contributed to the change in their level of interest in premedical studies, Berkeley students most often identified courses they had taken. Students’ responses to the question, “Were there any specific courses at Berkeley that discouraged your interest in medicine?” are shown in table 1.6.
As shown on the right side of the table, 28 of 29 URM students (97%) mentioned at least one course that discouraged their interest in medicine. Many of these students mentioned more than one course. By contrast, 22 of the 34 non-URM students (65%) mentioned at least one course as discouraging them.
For those students mentioning more than one course, the interviewer followed up with a question asking the student to identify the one course that was the most discouraging for them. Of the 28 URM students mentioning at least one course, chemistry was cited as the most discouraging course by 20 (71%). Of the 22 non-URM students mentioning at least one course, chemistry was cited as the most discouraging course by 12 (55%). For both groups of students, chemistry was cited between four and five times more often than the next courses, biology and math. It thus seems that, consistent with the results of our interviews with Stanford students, chemistry courses are the single most important factor that discourages students from continuing in premedical studies.
TABLE 1.6.
List of courses that discouraged students’ interest in premedical studies
While more than one-third of the non-URM students responded that none of their courses discouraged their interest in premedical studies, only one of the 29 URM students reported this absence of discouraging courses. It appears that chemistry and the other premedical courses at Berkeley are quite a bit more discouraging for URM students than for non-URM students.
Consistent with our concern that many of these URM students, especially those coming from a disadvantaged educational background, may be vulnerable to a loss of self-confidence during the early university experience with a resultant shifting of professional aspirations, we have excerpted from our interviews with six of the URM students at Berkeley specific text that addresses this issue. All six are female. We looked for any mention by the student during the interview of a course that was so discouraging that, as a result of having taken it, the student may have changed his or her aspiration regarding a career in medicine.
SUBJECT 1
Q: How would you compare your current level of interest in becoming a physician with the interest you had when you entered as a freshman?
A: I wanted to do it a lot freshmen year, but afterwards I stopped.
Q: What were the factors that led to the decrease in your level of interest?
A: I didn’t think that I could do very well in the chemistry classes.... I wanted to be premed when I first got here. But then after the first semester, I stopped.… I think a lot of students get scared after Chem IA [inorganic chemistry].
SUBJECT 2
Q: What were the factors that led to the decrease in your level of interest?
A: Chemistry. [laughter] Yeah, just the level of competitiveness here.... I’m sorry, but chemistry is just—having to take that much and study a lot it’s just—I don’t like doing that. So it’s just like why do that?...I’ve heard many experiences after taking Chem 3 [organic chemistry]. This is just like the peak. You like it or you don’t. This is the turnaround point.
SUBJECT 3
Q: How would you compare your current level of interest in becoming a physician with the interest you had when you entered as a freshman?
A: It’s changed a lot. Yeah, so. When I first came, I wanted to go into health care. And that’s what I knew I wanted to do. But then when I started taking the classes, it changed.
Q: What were the factors that led to the decrease in your level of interest?
A: Mainly just the classes and the level of difficulty in the classes. I had to repeat Chem IA.
SUBJECT 4
Q: Were there any specific courses that discouraged your interest in medicine?
A: I think having to drop Chem IA in the Spring of my first year made me question whether or not I could do it… . I really didn’t tell anyone because I didn’t want to seem stupid. And then when I eventually had to drop it, I remember like I was hiding from certain people because I didn’t want them to know. [laughter] … So it was just a matter of me not wanting to feel dumb around other people.
SUBJECT 5
Q: How would you compare your current level of interest in becoming a physician with the interest you had when you entered as a freshman?
A: Well, my first semester I was in Chem IA and calculus. And it was just like really, really big lectures and a lot of time. And I just felt like I wanted something that was smaller and more focused.... A lot of people get scared either before or after O-chem and decide they don’t like it [medicine] anymore.
Q: Were there any specific courses that discouraged your interest in medicine?
A: Chem IA. Introduction to Chemistry or whatever. I took it twice. Um, well once I dropped after the tenth week mainly because on my part I felt that I didn’t put enough effort. It just seemed like no matter how hard I tried, I would still probably do bad on the test and stuff like that.... That’s probably the class at Berkeley that discouraged me from being premed.... My friends also felt discouraged … They dropped out of their premed pursuit cuz of Chem IA.
Conclusions from Our Research
Among entering students at Stanford who initially are premed, women and under-represented minority students are less likely to maintain their interest in a medical career through four years of schooling. While each factor appears to exert a weakening influence independently, there is an important gender skewing that makes these effects cumulative. While 61 percent of the non-URM students in our study sample were female, 74 percent of URM students (88% of African American students) in our sample were female.
Among freshmen who enter Berkeley with an initial interest in pursuing premedical studies, we also see a clear pattern of a substantial reduction in the strength of that interest by the end of sophomore year. When we compare the Berkeley data to the data from Stanford, we see a substantially sharper decline in interest among Berkeley students. In addition, the decline is seen among all racial/ethnic groups at Berkeley, while at Stanford the decline in interest among white and Asian students was less than that among African American, Latino, or Native American students.
A principal cause of the decline in interest among premedical students seems readily apparent. Based on the results of our interviews, early experiences in the premedical science courses are frequently reported as having discouraged a student’s interest in continuing in premedical studies, with chemistry courses as the principal source of that discouragement. The discouraging effects of chemistry courses appear to be felt more acutely by URM students at both Berkeley and Stanford.
From the results of our interviews, it appears that the adverse effects of chemistry courses experienced by many of the URM students led directly to their questioning their own ability to continue to pursue a medical career and as a consequence dropping medicine as a possible career choice. At both Berkeley and Stanford, a majority of these URM students are women. For these students, entering college with the hope of becoming a physician and then having a negative experience in a chemistry course is a major turning point in their lives. In the words of one of the Berkeley students whose interview appears above, “I’m sorry, but chemistry is just... just like the peak. You like it or you don’t. This is the turnaround point.”
In our interviews with them, a number of Stanford students used the term “weeder course” to describe their experience in the chemistry classroom. Students perceive success in chemistry as essential to gaining admission to medical school. Perhaps the impact of this perception is best summarized by the Stanford URM student quoted above who said, “Everyone says it’s more like a weeding-out process than anything, and I just ended up being one of those people.”
Questioning the Orthodoxy of Premedical Education
At Stanford University and to a large extent at the University of California, Berkeley, incoming freshmen who aspire to become physicians face substantial pressure to enter the standard premedical curriculum early in their college careers. In most cases this means enrolling in freshman chemistry, followed in sequence by courses in biology and physics. Those who delay this process rapidly become aware that they are, in their own words, “off-track”—that they face a competitive disadvantage among their premedical peers in getting ready to apply to medical school.
As a result of including courses in chemistry in their early academic experiences, many of these students become discouraged, often giving up on their aspirations. We know that two groups of students are more likely to respond to their early experiences in the chemistry classroom by losing interest in a medical career: women and underrepresented minority students. The outcome of this sorting process is that these two universities, two of the most competitive in the country, contribute far fewer URM physicians to the American medical profession than they might.
In 2006 Dr. Ezekiel Emanuel, chair of the Department of Bioethics at the Clinical Center of the National Institutes of Health, published an article in JAMA questioning our continued reliance on the traditional premedical curriculum with its heavy emphasis on science courses. Dr. Emanuel suggested that “many premed requirements are irrelevant to future medical education and practice.” He went on to argue, “Why are calculus, organic chemistry, and physics still premed requirements? Mainly to ‘weed out’ students. Surely, it would be better to require challenging courses on topics germane to medical practice, research, or administration to assess the quality of prospective medical students, rather than irrelevant material.”14 By suggesting that calculus, organic chemistry, and physics are “irrelevant to future medical education,” Emanuel was challenging what has come to be the orthodoxy of premedical education.
To appreciate how widespread this orthodoxy has become, it is instructive to examine the Web site of the Princeton Review, a private firm that offers premedical students support in preparing for medical school in the form of books, classes, and private tutoring. On its Web site, the review advises students interested in going to medical school to complete one year of biology, one year of inorganic chemistry, one year of organic chemistry, one year of physics (all sciences with accompanying labs), and one year of English.15 Wikipedia, the increasingly important on-line source of common knowledge, offers advice that is essentially the same.16 At least for some of the most popular on-line sources of information regarding expectations for premedical students, there is general agreement that the road to medical school begins in the science classroom, and that every premedical student is well advised to take two years of chemistry, one year of biology, and one year of physics.
To confirm the consistency of this expectation among medical schools, I reviewed the minimum requirements for admission as listed on the Web sites of six of the leading medical schools in the country, each (as we will see later in this book) with an important historic role in the evolution of both medical education and premedical education:
• College of Physicians and Surgeons of Columbia University17
• Harvard University School of Medicine18
• Johns Hopkins University School of Medicine19
• University of California, San Francisco School of Medicine20
• University of Michigan School of Medicine21
• Stanford University School of Medicine22
While the schools approach the issue of English and math somewhat differently, each agrees that in order to gain admission premedical students must have completed two years of chemistry, one year of biology, and one year of physics.
The AAMC is explicit in describing what is expected of premedical students at most of its member schools:
The study and practice of medicine are based on modern concepts in biology, chemistry, and physics, and on an appreciation of the scientific method. Hence, mastery of these basic scientific principles is expected of all entering medical students. Medical schools typically require successful completion of one academic year … of biology and physics and one academic year each of general chemistry and organic chemistry.... All science courses should include adequate laboratory experience.23
If nearly all medical schools agree on the necessity of two years of chemistry, one year of physics, and one year of biology as the minimum acceptable preparation for entry into medical school, when and where was this norm established? Using information published by the AAMC, we find that these standards were set more than fifty years ago.
In 1950, the AAMC first published its Admission Requirements of American Medical Colleges. Looking at the 1951 issue of that handbook, we see that the six medical schools listed above all had substantially the same admission requirements in 1951 as they did in 2008.24 In 1951 they each listed two years of chemistry, a year of physics, and a year of biology as required for admission. Three of the schools wanted a semester of embryology in addition to the required year of biology. However, in 1951 they were unanimous on the need for the same basic science courses—chemistry, physics, and biology—that they required in 2008. For premedical students hoping to gain admission to these medical schools in 1951, as for students today, success in these sciences defines the orthodoxy of premedical education.
Apparently it was also the orthodoxy in 1924, when Sinclair Lewis wrote about his fictional premedical student, Martin Arrowsmith, for whom “the purpose of life was chemistry and physics and the prospect of biology next year.”25
It thus appears that, in his comments above suggesting that many of the standard premedical requirements are “irrelevant to future medical education and practice” and are there “mainly to ‘weed out’ students,” Ezekiel Emanuel was voicing a somewhat unorthodox view of premedical education. That this is so is reflected in some of the published responses to his remarks.26 Dr. Daniel Kramer, of Massachusetts General Hospital, responded to Emanuel’s assertions by arguing in support of organic chemistry: “I would not so hastily dismiss organic chemistry as a mere tool to thin the applicant herd. Indeed, I believe that no other premedical course so directly impacts clinical practice.... I remember very little about benzene rings, but the critical thinking and problem-solving skills of organic chemistry formed the foundation of my medical training.” Kramer appears to be arguing that it is not so much the specific knowledge base gained in the undergraduate study of organic chemistry that matters as it is the introduction to organic chemistry as a way of thinking and of reasoning.
Kramer’s argument is supported by that of Drs. Thomas Higgins and Scott Reed, surgeons from Eastern Virginia Medical School: “The value of organic chemistry and physics may be difficult to appreciate because medical care does not directly require remembering physics formulas or analyzing chemical structures; however, these disciplines contribute a great deal to providing the framework for understanding basic principles of medicine.”
Not all the writers, however, were so critical of Emanuel’s unorthodox recommendations. Dr. Virginia Collins and her colleagues from the American College of Physicians respond in their letter that “current premedical requirements reflect tradition rather than any particular educational rationale.”
In looking for the origins of our current understanding about what is orthodox and what is unorthodox in premedical education, one might well turn to the Flexner Report, published in 1910 and commonly understood to be a major contributor to the scientific revolution in medical education that took place in the United States in the early part of the twentieth century. There Flexner said of premedical education: “The normal rhythm of physiologic function must remain a riddle to students who cannot think and speak in biological, chemical, and physical language.”27
What was the basis of Flexner’s assertion? Was there scientific evidence to support his view? Did our current model of premedical education develop as a product of sound scientific reasoning, or might it simply have evolved based on a common set of beliefs? What is the empirical evidence that courses in chemistry, physics, and biology are fundamentally necessary to understanding the scientific reasoning on which the practice of medicine is based? It is crucially important to address these questions to be able fully to understand the implications of the current model of premedical education not only for the future ethnic diversity of the medical profession but also for its future intellectual diversity. I will address each of these questions in the following chapters.
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